guide to medi‐cal in santa clara county · for replacement of your medi-cal card, please contact...

SCD 2335 – 03/13

SOCIAL SERVICES AGENCY

GuidetoMedi‐CalinSantaClaraCounty

SantaClaraCounty SocialServicesAgency

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This handbook was produced by the collaborative effort of the following people:

Alice Turney Irasema Thompkins

Ivette Rodriguez Jasmin Balmonte

Lily Vasquez Margareta Hodzic

Rita Ursua

Santa Clara County Social Services Agency wishes to serve you in the best possible way and facilitate your understanding of the Medi‐Cal program. We hope this material will be a valuable resource to you.

Our Team would like to acknowledge Alameda County Social Services Agency for their contribution to this Medi‐Cal Guide.


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Table of Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 What is Medi‐Cal? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 How To Apply for Medi‐Cal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 The Medi‐Cal Application Process. . . . . . . . . . . . . . . . . . . . . . . . . . .7 Keeping Medi‐Cal Benefits Active. . . . . . . . . . . . . . . . . . . . . . . . . . . 8 What Medi‐Cal Covers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Restricted Scope. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Financial Responsibility. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 No Cost Medi‐Cal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Share of Cost (SOC). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Retroactive Medi‐Cal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 What a Medi‐Cal Card Looks Like. . . . . . . . . . . . . . . . . . . . . . . . . . .14 Medi‐Cal Health Plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Important Contact Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 Contacting the Social Services Agency. . . . . . . . . . . . . . . . . . . . . . . 18 Other Health Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Third Party Liability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Medicare Health Insurance Card. . . . . . . . . . . . . . . . . . . . . . . . . . . .22 Medicare Savings Programs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 Frequently Asked Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24


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INTRODUCTION

GUIDE TO MEDI-CAL IN SANTA CLARA COUNTY

This guide will help to answer the most commonly asked questions such as:

What is Medi-Cal? How do I apply? Where do I apply? What happens to my application when I apply? What does Medi-Cal covers? What is a Share of Cost?


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What is Medi-Cal? The Medi-Cal Program provides health care coverage for those who meet program eligibility requirements including:

Low-income families and children, Persons with permanent disabilities, Persons 65 years of age and over, Children in foster care, Pregnant women, Persons in skilled nursing facilities.

It is also designed to provide health coverage specifically to treat certain conditions such as:

Tuberculosis, Breast and cervical cancer (BCCTP), Kidney dialysis, HIV/AIDS, Organ transplants, Parenteral Hyperalimentation (tube feeding).


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How To Apply For Medi-Cal

You may complete a Medi-Cal application in one of the following ways: On-line at www.benefitscalwin.org , Print the Medi-Cal Mail-In Application from the State’s

website at http://www.dhcs.ca.gov/services/medi-cal/Pages/MediCalApplications.aspx . Complete the form and either Fax to (408) 295-9248 or Mail to one of the offices listed below.

Call our office for an application to be mailed to you at (877) 962-3633

You may apply in person at any of the offices listed below:

Assistance Application Center 1867 Senter Road

San Jose, CA 95110

South County District Office 379 Tomkins Court Gilroy, CA 95020

North County District Office

100 Moffett Boulevard Mountain View, CA 94043


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What happens when a Medi-Cal application is received at one of our offices?

STEP 1

The application is assigned and reviewed by an Eligibility Worker.

STEP 2 If necessary, the worker requests verification in writing and allows 10

days to provide the information to process the application.

STEP 3 The worker determines whether or not you are eligible once all

verifications are provided and reviewed Note: Your application may be denied if the required information or verifications are not provided by the due date.

STEP 4 A letter is sent to you within 45 days from the date we receive your

application explaining if the application was approved or denied. Note: If you apply on the basis of disability, there may be a delay in granting your Medi-Cal benefits as your disability claim is determined by a State agency and not Social Services.

STEP 5 If you are approved and have never received Medi-Cal before, a

Benefit Identification Card will be mailed to you by the State of California,

OR Your Benefit Identification Card is reactivated if you had Medi-Cal coverage in the past.

IMPORTANT

Medi-Cal beneficiaries are mandated to enroll in a Managed Care Plan if they reside in Santa Clara County and receive no share-of-cost, full scope benefits. If you are required to enroll in a Medi-Cal health care plan, you will receive an enrollment packet. You must choose a health care plan within 30 days or one will be chosen for you. You will receive a separate health care identification card in addition to the Benefit Identification Card. Refer to page 15 for more information.


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How to Keep Your Medi-Cal Active.

Midyear Status Report

Some Medi-Cal beneficiaries may be required to submit a Midyear Status Report in order to keep Medi-Cal benefits. One will be mailed to you if required.

IMPORTANT

You must return the Midyear Status Report by the due date in order to continue Medi-Cal benefits.

Medi-Cal Annual Redetermination

STEP 1 Every year, you must complete a new packet of Medi-Cal forms which will be mailed to you. You must mail the forms and any requested verifications by the due date.

STEP 2 Your Medi-Cal forms will be reviewed by a worker for ongoing

eligibility. The worker may request any missing verifications.

STEP 3 Once all the forms and verifications are received and you

continue to be eligible, Medi-Cal benefits are renewed for one full year.

NOTE: You must submit the required forms and verifications by the due date. If your Medi-Cal stops and you were enrolled in a Medi-Cal health care plan, you may be dropped from the plan.

IMPORTANT Remember to report any changes that affect your Medi-Cal within ten days.


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What Medi-Cal Covers:

Your coverage will be determined based on your immigration status. Your immigration status will determine if you are eligible for either “Full Scope Medi-Cal” or “Restricted Scope Medi-Cal.” Full Scope Medi-Cal Benefits for U.S. citizens and persons with satisfactory immigration status include:

Doctor Visits Hospital Care Emergency Visits Lab Tests Approved Prescriptions Dental Care for Children Vision Care Mental Health Services Preventive Care, including Examinations and Vaccinations Pregnancy and Postpartum Care Family Planning STD Tests and Treatment X-Rays and Mammograms Medical Supplies Skilled Nursing Tuberculosis Renal Dialysis Approved Medical Equipment

NOTE: Some services may require prior approval. Your health care provider will explain if it applies to you. Contact the State of California, Medi-Cal Benefits Branch at (916) 552-9797 if you have any questions about what Medi-Cal covers.


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Restricted Scope Medi-Cal Benefits for persons without satisfactory immigration status include:

--Emergency Care as determined by the provider --Pregnancy and Postpartum care --Tuberculosis --Renal Dialysis --Confidential Services for Minors under 21

Financial Responsibility

Once determined eligible, your gross monthly income less Medi-Cal’s applicable deductions will determine if you are entitled to receive no cost Medi-Cal or if you have a share of cost to meet.

No Cost Medi-Cal

If your income is below the Medi-Cal income level you may receive Medi-Cal benefits at no cost to you.


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Share of Cost (SOC)

If your income is above the Medi-Cal income level, you may be responsible to pay a certain amount in the month medical services are provided before Medi-Cal pays. You will not pay the share of cost in any month you do not receive medical services.

Example:

A family of 4 Total countable monthly income $1600 Medi-Cal limit for family of 4 1100 Share of Cost (SOC) $ 500

A SOC is determined on a case by case basis. Medi-Cal has special no SOC programs based on a family’s income. Your worker will review all no SOC programs for which you may be eligible.

Generally, SOC applies to the family as a whole and not to the individuals. For example, if the family’s SOC is $500 and you already paid $500 towards your medical bills, your family’s SOC for the current month has been met. The other family members will no longer need to pay for any medical services in the month in which the SOC was met.

How do I meet the Share of Cost (SOC)? The SOC is paid to your provider and not to the Social Services Agency. When you incur medical expenses that equal your SOC, your SOC has been met. Your provider will record the amount you paid or are responsible to pay. Once your SOC is met, Medi-Cal will pay any other covered medical expense for you or your family in that month.

Example:

Family of 4 with a SOC of $500: Mom incurs a hospital bill of $3,000. The amount she is responsible to pay the hospital is $500. Medi-Cal will pay the remaining $2,500. Her child visits a doctor in the same month. Medi-Cal will cover the entire cost of the child’s medical services because the SOC was met for that month.


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Do I pay the SOC every month? You only pay your SOC in the month you receive medical services. You do not pay the SOC in the month you do not receive medical services.

If I reside in a skilled nursing home, do I pay my SOC monthly? Yes, if your Medi-Cal is approved, and you are in a skilled nursing home, your SOC must be met each month.


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Retroactive Medi-Cal

Retroactive Medi-Cal is a program available upon request to applicants or beneficiaries who are or have been eligible for Medi-Cal and have an unpaid medical bill in any of the three months preceding the month of application. The request for retroactive coverage must be made within one year of the month in which the service was provided to you. You may need to provide verification of income and property for each month requested.

Example:

A family applied and is approved for Medi-Cal in October 2011. The family would be potentially eligible for retroactive Medi-Cal for any or all the following months: July, August, and September 2011. The family has an unpaid medical bill for August 2011. They have until July 31, 2012, to request Medi-Cal for the month of August 2011.


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What A Medi-Cal Card Looks Like:

The Medi-Cal Benefits Identification Card (BIC) is a white plastic card with Blue letters on the front and black letters on the back. The actual size is 3 ½”x 2 1/8”. A picture of the card is below.

If you are approved for Medi-Cal and you have not received Medi-Cal in the past, the Department of Health Care Services will mail you a card. If you are approved and had Medi-Cal in the past, your Medi-Cal card will be reactivated.

For replacement of your Medi-Cal card, please contact the Social Services Agency at (408) 758-4600.

ALWAYS SHOW YOUR MEDI-CAL CARD TO YOUR PROVIDER WHEN

YOU RECEIVE SERVICES.


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Medi-Cal Health Plans

When you are approved for no cost full scope Medi-Cal, you may be required to enroll in one of two Medi-Cal Health Care Plans in Santa Clara County. An enrollment packet will be sent to you by Health Care Options.

It is very important that you read all materials carefully and select a Health Plan and provider within 30 days. Health Care Options is available to assist you with enrollment or disenrollment in a Medi-Cal Health Plan. If you are applying for Medi-Cal in person, see the Health Care Options representative located in the lobby.

If you have a specific medical condition you may request an exemption from enrolling in a Medi-Cal Health Plan.

Call Health Care Options at 1-800-430-4263 to:

Select the best health plan for you and your family Attend a presentation explaining the Health Plans Enroll or disenroll in Santa Clara Family Health Plan or Anthem Blue Cross Apply for an Exemption

You must choose either:

Santa Clara Family Health Plan 210 East Hacienda Avenue Campbell, CA 95008 1-800-260-2055

OR

Anthem Blue Cross P.O. Box 60007 Los Angeles, CA 90060-0007 1-800-407-4627


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Call your health plan once you are enrolled to: Request a list of providers Set up an appointment Clarify billing issues Ask about specific medical or prescription drug benefits Change doctors within your plan Add or remove family members from coverage Report address or phone number changes Request a member replacement ID Card

What the Santa Clara Valley Health Plan card looks like:

What the Blue Cross cards looks like:

ALWAYS CARRY YOUR MEMBER ID CARD WITH YOU


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IMPORTANT CONTACT INFORMATION:

Patient Access, Financial Counseling Center (Valley Medical Center) 1‐866‐967‐4677

Access for Infants and Mothers 1‐800‐433‐2611

Adult Protective Services 1‐800‐414‐2002

Anthem Blue Cross: 1‐800‐407‐4627

California Children’s Services in Santa Clara County 408‐793‐6200 or 408‐793‐6250

Child Health and Disability Prevention Program: 800‐689‐6669 or 408‐937‐2256

Child Support or Medical Support: 1‐866‐901‐3212

Child Abuse Hotline 408‐299‐2071

Children’s Health Initiative 1‐888‐244‐5222

Denti‐Cal ‐‐ 1‐800‐322‐6384 to find a dentist or dental benefits for children

Healthy Families Program: 1‐800‐880‐5305

Health Insurance Counseling and Advocacy Program (HICAP) 1‐888‐434‐0222

Housing Authority 408‐275‐8770

In‐Home Supportive Services: 408‐975‐4899

Medi‐Cal Billing: 916‐636‐1980 for Medi‐Cal problems or questions about a bill.

Medicare: 1‐800‐633‐4247

Medicare Part D (Low Income Subsidy) 1‐800‐772‐1213

Medi‐Cal fraud 1‐800‐822‐6222

Mental Health Services 408‐885‐5673

Next Door Solutions to Domestic Violence: 408‐501‐7550; hotline 408‐279‐2962

Planned Parenthood 408‐297‐5090

Santa Clara Family Health Plan 1‐800‐260‐2055

Santa Clara Public Guardian’s Office 408‐755‐7610

Santa Clara County Veteran Affairs Office 408‐553‐6000

Second Harvest Food Bank 408‐266‐8866

Senior Adult Legal Assistance (SALA) 408‐794‐5250

Social Security: 1‐800‐772‐1213

Support Network for Battered Women 1‐800‐572‐2782

Valley Medical Center 408‐885‐5000

Women Infants and Children Program 408‐792‐5101

4 Community Child Care Council of Santa Clara County 408‐457‐3100

California Nursing Home Guide (CANHR) www.canhr.org


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Contacting the Social Services Agency

Call (408) 758-3600 to: Report any changes within ten days Check on your Medi-Cal eligibility status Add or remove a family member Report address or phone number changes Report income changes Request a replacement Medi-Cal card.


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Other Health Coverage (OHC)

Other health coverage (OHC) is benefits for health-related services under any private or group insurance program. You can have OHC and Medi-Cal at the same time. However, California State law requires Medi-Cal applicants or beneficiaries to report and use OHC they may have before using Medi-Cal.

On a monthly basis the Department of Health Care Services generates a data match with health insurance providers in the state; and if there is a match, automatically posts OHC on the individual’s Medi-Cal record. If your OHC stops or you have questions about your OHC, you may call the Department of Health Care Services, Recovery Division, at 1-800-952-5294.

Current premiums paid for private or group medical insurance must be reported to Social Services Agency. We will use the premium amounts paid to ensure accurate budget computations. Premiums paid for OHC may be counted as a deduction from your gross income.

Example: A family of 4 applying for Medi-Cal. One person in the household has Kaiser Permanent as other health insurance and pays $50 per month. The premium amount paid to Kaiser is a deduction to the family’s gross income. In order to receive a deduction for the premiums paid to the other health insurance, proof must be provided to Social Services Agency.


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Third Party Liability

Medi-Cal regulations require reimbursement of medical services from those who might have filed a claim against a potential liable third party. Example of a third party liability medical claim may be when a person is injured on the job and a claim for workers’ compensation is filed. The person injured may apply for Medi-Cal.

For more information on Other Health Coverage and Third Party Liability, call toll free 1-

800-952-5294.


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Medicare

Medicare is a national health insurance program administered by the Social Security Administration that pays for certain medical services to individuals entitled to coverage.

Individuals are eligible for Medicare if they or their spouse worked for at least 10 years in Medicare covered employment, and they are 65 years of age or older and a citizen or permanent legal resident of the United States. Younger individuals with a disability or chronic kidney disease may also qualify.

Medicare is divided into two parts: Part A Part A Hospital Insurance is available to qualifying persons at no cost and helps pay for inpatient hospital care, limited care in a skilled nursing facility, home health care, and hospice care. Individuals who do not qualify for free Part A coverage can purchase such coverage through payment of a monthly premium.

Part B Part B Medical Insurance may be purchased from Health Care Financing Administration (HCFA) through payment of a monthly premium. Part B helps pay for doctor’s services, outpatient hospital services, durable medical equipment, and a number of other medical services and supplies that are not covered by the hospital insurance part of Medicare.


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Medicare Health Insurance Card Medicare Health Insurance Cards are prepared and mailed by the Social Security Administration and the Railroad Retirement board to beneficiaries who are eligible to receive Medicare benefits. The red, white, and blue card shows the name of the beneficiary, Medicare Claim Number, the sex of the beneficiary, entitlement to Medicare Part A and/or Part B, and the effective date of each. The card also contains a beneficiary’s signature block. A Medicare beneficiary receives a new card each time Medicare eligibility status changes.

The actual card size is 3 ½” (length) by 2 ¼” (width).

For more information regarding Medicare, call toll free 1-800-633-4227.


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Medicare Savings Programs

Qualified Medicare Beneficiary (QMB) Program This program helps Medicare beneficiaries pay for their Medicare Part A and Part B premiums, co-insurance, and deductibles. To be eligible you must be eligible for Medicare Part A, have income and property within a certain limit, be otherwise eligible for full scope Medi-Cal. There is no requirement to actually apply for Medi-Cal.

SSI/QMB Beneficiary Individuals who receive Supplemental Security Income (SSI) may also apply for QMB benefits as they meet all Medi-Cal requirements by virtue of being eligible for SSI.

Specified Low-Income Medicare Beneficiary (SLMB) Program Individuals who do not qualify for QMB because their income is over the QMB limit may qualify for SLMB if their income is within the SLMB income limits. The SLMB program pays only for the Medicare beneficiary’s Part B premium. All other QMB eligibility criteria apply.

Qualifying Individual (QI) Program This program is similar to the QMB and SLMB programs except for a higher income limit. This program pays only for the Medicare Part B premium.


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Frequently Asked Questions (FAQs):

1. Who may be eligible to receive Medi-Cal benefits?

Applicants must fall under one of these categories: Families with children Persons under 21 or over 65 years of age Pregnant women Blind and disabled persons Residents of nursing homes or long term care Refugees Persons infected with Tuberculosis Persons that need kidney dialysis or tube-feeding There are other specialized categories you may be eligible or such as

o Payment of your Medicare premiums, deductibles and co-insurance o Breast and Cervical Cancer Treatment program o Organ Transplant Medication

You are automatically eligible to receive Medi-Cal if you receive cash assistance under one of these programs:

Supplemental Security Income (SSI) California Work Opportunity and Responsibility to Kids Program (CalWORKs) Refugee Cash Assistance (RCA) Foster Care or Adoption Assistance

2. What do I need to provide to apply for Medi-Cal?

You must provide verification of income, property, identity, and California residency. Other verifications may be requested if they are needed.


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3. How long does the application process take? Forty-five days are allowed by law to process a Medi-Cal application. An application may take 90 days or more if a disability evaluation is involved.

4. I have unpaid medical bills from past months. Can I apply for Medi-Cal for these months? Yes. You can apply for any of the three months prior to the month of application.

5. I am a minor (under 21) living with my parents; can I apply for Medi-Cal? If you are living with your parents you may apply for confidential Minor Consent benefits without parental consent. You must apply in person. If you are living outside your parents’ home and they are not claiming you as a tax dependent, you can apply for yourself.

6. What is Minor Consent? Minor Consent Program is a program for minors under 21 years of age who live with their parents and are unmarried. This Program covers certain confidential medical services such as family planning, pregnancy, drug/alcohol abuse, sexually transmitted diseases, sexual assault, and mental health.

7. What if I don’t qualify for Medi-Cal, what are my options? Persons who are between 21 and 64 years of age who are and don’t qualify for Medi-Cal may be eligible for the Ability to Pay Program Determination (APD) at Valley Medical Center (refer to page 15 of this pamphlet for contact information).

8. Can I apply for Medi-Cal if I own a home and a car?

The home you live in is not counted toward your property limit. One car may be exempt. Your property limit is based on the size of your family.

9. How will my Medi-Cal benefits affect my estate?


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Medical expenses paid by Medi-Cal after age 55 are subject to recovery by the State. After receiving notification of the death of a person on Medi-Cal, the State of California will decide whether or not the cost of services must be paid back. For more information, call Department of Health Care Services Estate Recovery Section: (916) 650-0490.

10. I am leaving the State for a while. What will happen to my Medi-Cal? If you are gone longer than 60 days, your case will be discontinued and you will need to re-apply when you return.

11. I moved to another county, will Medi-Cal cover my medical bills in the new county?

As soon as you move, please report your new residence address and phone number to our Agency. We will send all the necessary paperwork to your new county so that there will be no interruption to your Medi-Cal benefits. If you are in a Medi-Cal Managed Care Plan, please call your plan right away to report the change of address.

12. My husband has returned to our home. I want to add him to my Medi-Cal case. What do I do? Please report this change to our Agency as soon as he returns (within 10 days of his return). You will be asked to provide identifying information, income and property along with verifications. The worker will mail you all the required forms for you to complete and return.

13. If I don’t agree with the County’s decision. What can I do? The back of every Notice of Action has information and a phone number about your hearing rights and explains how to ask for a hearing. You have 90 days to ask for a hearing. The 90 days start the day after the county gives or mails the Notice of Action. You may complete the hearing form on the back of the notice and return to the address indicated on the form or you can call the toll free number 1-800-952-5253.


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14. What is Transitional Medi-Cal and why am I aided under this program? This program is for persons who were discontinued from CalWORKs/1931(b) due to qualifying reasons. It provides additional months of no cost Medi-Cal If you have questions, contact our Agency at (408) 758-3600. 15. What is the 250% Working Disabled Program? The Medi-Cal Working Disabled Program is a special program for disabled people who are working. If you are eligible, you will pay a premium each month to receive no share of cost Medi-Cal. There are income and property limits.

16. I was discontinued from SSI. Can I apply for Medi-Cal? When SSI is discontinued, your Medi-Cal benefits will continue until an evaluation of on-going eligibility is completed by the Social Services Agency. You will be notified and contacted for additional information.

guide to medi‐cal in santa clara county · for replacement of your medi-cal card, please contact...

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